Pre Employment Application Form – Fill Out and Use This PDF

A Pre Employment Application form is a comprehensive document used by organizations to collect pertinent information from individuals seeking employment. It encompasses a wide array of data points, including personal details, educational background, previous employment history, and specific qualifications or licenses relevant to the position applied for. Filling out this form accurately is the first critical step towards securing a potential job opportunity. Ready to take that step? Click the button below to begin your application process.

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Pre Employment Application Form PDF Details

The pre-employment application form serves as an essential medium through which candidates express their interest in job opportunities at the New York City Department of Health and Mental Hygiene. This form, meticulously designed to capture a comprehensive range of information, ensures a systematic approach to the recruitment process. It begins with basic details, including the position desired and the source of referral, and extends to personal information such as citizenship status, age, and military service. Educational backgrounds from high school through postgraduate levels are scrutinized, with a particular emphasis on diplomas, degrees, and fields of study. Moreover, it delves into the medical training and experience of the applicant, highlighting internships, residencies, fellowships, and private practice specifics. Licensure information pertinent to the position sought is requested to confirm qualifications. Employment history is meticulously documented, asking for a detailed account of past roles, responsibilities, supervisory experience, and the reason for leaving past positions. The form additionally inquires about skills, including language proficiencies and clerical capabilities. The declaration at the end of the form underscores the importance of honesty and the implications of providing false information. Adherence to equal opportunity principles is affirmed, indicating a commitment to fairness and legal compliance in hiring. Overall, the pre-employment application form is a crucial document that facilitates an equitable and thorough evaluation of potential employees, ensuring that candidates are assessed based on their qualifications, experiences, and skills relevant to the roles they aspire to fill.

Question	Answer
Form Name	Pre Employment Application Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	new york pre employment form, working papers in new york to print, working papers, printable working papers for minors in ny

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NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE

RECRUITMENT OFFICE

7+675((75')/225BOX 39 48((16NEW YORK

POSTING NO.

POSITION DESIRED

❑ F/T

❑ P/T

PRE-EMPLOYMENT APPLICATION

SOURCE OF REFERRAL

Please Print in Black Ink or Type

LAST NAME

FIRST

MIDDLE INITIAL

SOCIAL SECURITY NO.

TELEPHONE NO.

ADDRESS

CITY OR BOROUGH

STATE

ZIP CODE

CITIZENSHIP

ARE YOU 18 YEARS OR OLDER

U.S. ARMED FORCES SERVICE – BRANCH OF SERVICE U.S.

❑ U.S. CITIZEN

❑ YES ❑ NO

❑ VETERAN

❑ DISABLED VETERAN

❑ RESIDENT ALIEN

DATE OF ENTRY

DATE OF DISCHARGE

❑ NON-RESIDENT ALIEN

IF NO, STATE AGE

ARMED FORCES OCCUPATION

PREVIOUS NEW YORK CITY EMPLOYMENT (AGENCY & DATES)

INDICATE ANY OTHER NAME USED ON EMPLOYMENT RECORDS

EDUCATION

ATTENDANCE

NAME AND ADDRESS OF SCHOOL

DIPLOMA &

EDUCATION

FROM

INCLUDE FULL STREET ADDRESS,

MAJOR COURSE

DID YOU

DEGREE

CITY, STATE AND ZIP CODE

LEVEL

MO/YR

OF STUDY

GRADUATE

RECEIVED

NAME

❏ YES

HIGH SCHOOL

OR EQUIVALENT

ADDRESS

❏ NO

NAME

❏ YES

NURSING

❏ NO

ADDRESS

SCHOOL

NAME

❏ YES

COLLEGE OR

UNIVERSITY

ADDRESS

❏ NO

NAME

❏ YES

POST

GRADUATE

ADDRESS

❏ NO

MEDICAL TRAINING & EXPERIENCE

FROM

MO. YR. MO. YR.

INTERNSHIPS, RESIDENCES, FELLOWSHIPS, PRIVATE PRACTICE

NAME AND ADDRESS OF HOSPITAL (OR OFFICE IF PRIVATE PRACTICE)

(a) INTERNSHIP			INDICATE IF FORMAL OR SUB. APPT.
(b) RESIDENCY			INDICATE SERVICE ASSIGNED TO
(c) PRIVATE PRACTICE			INDICATE NATURE OF PRACTICE

LICENSE

IF A LICENSE OR PROFESSIONAL REGISTRATION IS REQUIRED FOR THE POSITION, PLEASE COMPLETE THE FOLLOWING:

TITLE OF LICENSE YOU POSSESS (VALID IN N.Y.)

LICENSE NO.

NAME OF ISSUING AGENCY

DATE OF ORIGINAL ISSUE

DATE LAST RENEWED

DATE OF EXPIRATION

RENEWAL NO.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

Federal and State law prohibits discrimination in employment because of age, ancestry, color, creed, liability for service in the U.S. armed forces, marital status, national origin, the presence of a non-job-related medical condition or handicap, political activity, race, sex, or sexual orientation.

PE 6 (REV. 8/04)

(Continue on reverse side)

EMPLOYMENT RECORD

LIST MOST RECENT EMPLOYMENT FIRST (IF MORE SPACE IS REQUIRED TO ACCOUNT FOR AT LEAST YOUR LAST 10 YEARS OF WORK EXPERIENCE, PLEASE

CONTINUE ON SEPARATE EMPLOYMENT RECORD SHEET AND ATTACH FIRMLY)

DATES EMPLOYED

NAME AND ADDRESS OF EMPLOYER

DESCRIPTION OF WORK (INCLUDE NUMBER AND KIND OF EMPLOYEES

MO. / YR.

SUPERVISED, IF ANY)

FROM

PHONE NO. (

)

NATURE OF BUSINESS

SUPERVISOR'S NAME AND TITLE

EXACT TITLE OF YOUR POSITION

ANNUAL SALARY

REASON FOR LEAVING

DATES EMPLOYED

NAME AND ADDRESS OF EMPLOYER

DESCRIPTION OF WORK (INCLUDE NUMBER AND KIND OF EMPLOYEES

MO. / YR.

SUPERVISED, IF ANY)

FROM

PHONE NO. (

)

NATURE OF BUSINESS

SUPERVISOR'S NAME AND TITLE

EXACT TITLE OF YOUR POSITION

ANNUAL SALARY

REASON FOR LEAVING

DATES EMPLOYED

NAME AND ADDRESS OF EMPLOYER

DESCRIPTION OF WORK (INCLUDE NUMBER AND KIND OF EMPLOYEES

MO. / YR.

SUPERVISED, IF ANY)

FROM

PHONE NO. (

)

NATURE OF BUSINESS

SUPERVISOR'S NAME AND TITLE

EXACT TITLE OF YOUR POSITION

ANNUAL SALARY

REASON FOR LEAVING

DATES EMPLOYED

NAME AND ADDRESS OF EMPLOYER

DESCRIPTION OF WORK (INCLUDE NUMBER AND KIND OF EMPLOYEES

MO. / YR.

SUPERVISED, IF ANY)

FROM

PHONE NO. (

)

NATURE OF BUSINESS

SUPERVISOR'S NAME AND TITLE

EXACT TITLE OF YOUR POSITION

ANNUAL SALARY

REASON FOR LEAVING

DATES EMPLOYED

NAME AND ADDRESS OF EMPLOYER

DESCRIPTION OF WORK (INCLUDE NUMBER AND KIND OF EMPLOYEES

MO. / YR.

SUPERVISED, IF ANY)

FROM

PHONE NO. (

)

NATURE OF BUSINESS

SUPERVISOR'S NAME AND TITLE

EXACT TITLE OF YOUR POSITION

ANNUAL SALARY

REASON FOR LEAVING

SKILLS

FOREIGN LANGUAGES

CLERICAL

ADDITIONAL QUALIFICATIONS

READ

WRITE

SPEAK

❏

TYPING

WPM

❏

SHORTHAND

WPM

❏

TRANSCRIPTION

WPM

MINIMUM SALARY REQUIREMENTS

PER ❏ HOUR

❏ YEAR

APPLICANT’S CERTIFICATION AND AGREEMENT – PLEASE READ CAREFULLY, SIGN AND DATE BELOW

I certify that the information I have provided in this employment application is correct and complete to the best of my knowledge. I realize that my willful omission or any misrepresentation of facts will be just cause for the rejection of this application or the termination of my services after employment. I understand that any employment which may be offered to me will be on a probationary basis and will be contingent upon my passing a physical examination and verification of my education records and employment history. I agree to cooperate and release those supplying any information from all liability.

	APPLICANT’S FULL SIGNATURE	DATE SIGNED
Thank you for completing this application.	APPLICANT’S FULL SIGNATURE	DATE SIGNED
It will be kept on file for one year ONLY!

MAIL TO:	NYC DEPARTMENT OF HEALTH AND MENTAL HYGIENE
	7+675((7 5')/225 BOX 39
PE 6 (REV. 8/04)	QUEENS, NEW YORK 11101

Pre Employment Application Form – Fill Out and Use This PDF

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